CASE REPORT

Pregnancy After Uterine Artery CASE 1 A 33-year-old primigravida at 24 weeks’ gestation expe- Embolization rienced premature rupture of membranes. Her antenatal course was complicated by uterine leiomyomata. She Jay Goldberg, MD, Leonardo Pereira, MD, and had undergone an abdominal myomectomy 6 years prior because of pain and menometrorrhagia. With con- Vincenzo Berghella, MD tinued symptoms and additional leiomyomata docu- Department of and Gynecology, Jefferson Medical College, Thomas mented on ultrasound, a uterine artery embolization was Jefferson University, Philadelphia, Pennsylvania performed the following year, 5 years before the de- scribed . Her symptoms resolved after the BACKGROUND: Uterine artery embolization is an increas- embolization. ingly popular alternative to and myomec- At the time of the present admission, with no evidence tomy as a treatment for uterine leiomyoma. Whether this of infection, the patient received two doses of betametha- procedure is safe for women desiring future fertility is sone (12 mg intramuscularly). Intravenous ampicillin controversial. and erythromycin were administered for 48 hours, fol- CASES: A primigravida who had previously undergone lowed by oral amoxicillin and erythromycin for 7 days. uterine artery embolization had premature rupture of She was managed expectantly as an inpatient for 4 membranes at 24 weeks. She had a cesarean delivery at 28 weeks, until she developed evidence of weeks, which was followed by uterine atony requiring at 28 weeks’ gestation. Because of her history of myo- hysterectomy. A primigravida who had previously under- mectomy, as well as a breech presentation, a cesarean gone uterine artery embolization delivered appropriately delivery was performed. No residual leiomyomata were grown dichorionic twins at 36 weeks. An analysis of the 50 noted. A 1673-g male was delivered, with Apgar published cases of pregnancy after uterine artery emboli- zation revealed the following complications: malpresenta- scores of 7 and 8 at 1 and 5 minutes, respectively. The tion (17%), small for gestational age (7%), premature deliv- was delivered manually and noted to be slightly ery (28%), cesarean delivery (58%), and postpartum adherent. We noted significant from the endo- hemorrhage (13%). metrial lining, which appeared necrotic and ragged. CONCLUSION: Women who become pregnant after uterine Uterine atony developed and did not respond to vigor- artery embolization are at risk for malpresentation, pre- ous uterine massage, , methylergonovine, pros- term birth, cesarean delivery, and postpartum hemor- taglandin F2␣, or per the rectum. A supra- rhage. (Obstet Gynecol 2002;100:869–72. © 2002 by cervical hysterectomy was performed. Estimated The American College of Obstetricians and Gynecolo- loss was 8000 mL. In treating the disseminated intravas- gists.) cular that developed, the patient was trans- fused 15 U of fresh frozen plasma, 14 U of packed red blood cells, and 8 U of platelets. Pathology of the and placenta showed residual necrotic placental tissue Uterine artery embolization is an increasingly popular with acute inflammation extending into the alternative to hysterectomy and myomectomy as a treat- and acute chorioamnionitis with funisitis. The patient ment for uterine leiomyomata. It was first reported as an did well postoperatively and was discharged home on effective primary treatment for symptomatic leiyomyo- postoperative day 8. The infant also did well and was 1 mata in 1995. Whether this procedure is safe for women discharged home at 8 weeks of life. desiring future fertility is controversial. There are very few data regarding the outcomes of after embolization. We present two cases of pregnancy in CASE 2 women who had previously undergone uterine artery A 42-year-old primigravida with dichorionic twins pre- embolization. sented at 26 weeks with preterm labor and cervical dilation of 2 cm. Her antenatal course was complicated Address reprint requests to: Jay Goldberg, MD, Thomas Jefferson University, Jefferson Medical College, Department of Obstetrics and by uterine leiomyomata and infertility. Three years be- Gynecology, 834 Chestnut Street, Suite 400, Philadelphia, PA 19107; fore conception she had undergone uterine artery embo- E-mail: [email protected]. lization for symptoms of pain and menometrorrhagia.

VOL. 100, NO. 5, PART 1, NOVEMBER 2002 0029-7844/02/$22.00 869 © 2002 by The American College of Obstetricians and Gynecologists. Published by Elsevier Science Inc. PII S0029-7844(02)02347-5 Table 1. Published Cases of Pregnancy After Uterine Artery Embolization Indication for Pregnancy Birth Case Reference embolization outcome weight Comments 1 Forssman (1982)3 AVM Term CD AGA Elective CD 2 Chapman (1985)4 GTD/AVM 32-wk, CD AGA Previa, PTL, postpartum hemorrhage 3 Poppe (1987)5 AVM 35-wk, SVD AGA PTL 4 Tacchi (1988)6 GTD/AVM 30-wk, CD AGA , listeriosis 5 Pattinson (1994)7 Term SVD AGA IVF 6 Chow (1995)8 AVM Term SVD AGA Postpartum hemorrhage 7 Gaens (1996)9 AVM 34-wk, delivery AGA 8 McIvor (1996)10 GTD “Infant” NA 9 McIvor (1996)10 GTD “Infant” NA 10 McIvor (1996)10 GTD “Infant” NA 11 Stancato-Pasik (1997)11 Previa/accreta Term SVD NA 12 Stancato-Pasik (1997)11 Accreta/abruptio placentae Term SVD NA 13 Bradley (1998)12 Leiomyomata NA NA 14 Ravina (2000)13 Leiomyomata 28-wk, SVD AGA AIDS, streptococcal septicemia 15 Ravina (2000)13 Leiomyomata SAB NA AMA (41 y old) 16 Ravina (2000)13 Leiomyomata 35-wk, CD AGA/SGA Twins, preeclampsia 17 Ravina (2000)13 Leiomyomata SAB NA AMA (40 y old) 18 Ravina (2000)13 Leiomyomata SAB NA AMA (41 y old) 19 Ravina (2000)13 Leiomyomata SAB NA AMA (42 y old) 20 Ravina (2000)13 Leiomyomata SAB NA AMA (42 y old) 21 Ravina (2000)13 Leiomyomata Term CD AGA Elective CD 22 Ravina (2000)13 Leiomyomata Term SVD SGA 23 Ravina (2000)13 Leiomyomata Term CD AGA Elective repeat CD 24 Ravina (2000)13 Leiomyomata Term CD AGA Failed induction at 42 wk 25 Ravina (2000)13 Leiomyomata Term SVD AGA 26 Vashisht (2001)14 Leiomyomata Term CD AGA 27 Ciraru-Vigneron (2001)15 Leiomyomata Term SVD NA 28 Ciraru-Vigneron (2001)15 Leiomyomata Term SVD NA 29 Ciraru-Vigneron (2001)15 Leiomyomata Term CD NA Elective CD 30 Ciraru-Vigneron (2001)15 Leiomyomata SAB NA 31 Ciraru-Vigneron (2001)15 Leiomyomata TAB NA 32 McLucas (2001)16 Leiomyomata Term SVD AGA 33 McLucas (2001)16 Leiomyomata Term CD AGA CPD 34 McLucas (2001)16 Leiomyomata Term CD AGA Breech, preeclampsia 35 McLucas (2001)16 Leiomyomata Term SVD AGA 36 McLucas (2001)16 Leiomyomata Term SVD AGA 37 McLucas (2001)16 Leiomyomata Term CD AGA CPD 38 McLucas (2001)16 Leiomyomata Term CD AGA Breech 39 McLucas (2001)16 Leiomyomata 32-wk, CD AGA Previa, abruption 40 McLucas (2001)16 Leiomyomata Term CD AGA Breech 41 McLucas (2001)16 Leiomyomata Term CD AGA Prior myomectomy 42 McLucas (2001)16 Leiomyomata SAB NA 43 McLucas (2001)16 Leiomyomata SAB NA 44 McLucas (2001)16 Leiomyomata SAB NA 45 McLucas (2001)16 Leiomyomata SAB NA 46 McLucas (2001)16 Leiomyomata SAB NA SAB at 16 wk 47 McLucas (2001)16 Leiomyomata NA NA 48 McLucas (2001)16 Leiomyomata NA NA 49 Goldberg (2002) (current case) Leiomyomata 28-wk, CD AGA 24-wk PPROM, breech, prior myomectomy, hysterectomy for uterine atony 50 Goldberg (2002) (current case) Leiomyomata 36-wk, CD AGA/AGA AMA (42 y old), IVF, prior myomectomy, twins, PTL, breech/ vertex presentation AVM ϭ uterine arteriovenous malformation; CD ϭ cesarean delivery; AGA ϭ adequate for gestational age; GTD ϭ gestational trophoblastic disease; PTL ϭ preterm labor; SVD ϭ spontaneous vaginal delivery; IVF ϭ in vitro fertilization; NA ϭ not available; AIDS ϭ acquired immunodeficiency syndrome; SAB ϭ spontaneous ; AMA ϭ advanced maternal age (Ͼ35 y); SGA ϭ small for gestational age; TAB ϭ therapeutic abortion; CPD ϭ cephalopelvic disproportion; PPROM ϭ preterm premature rupture of membranes. Table 2. Pregnancy Rates After Uterine Artery Embolization Postpartum Premature Smallness for Spontaneous hemorrhage delivery Cesarean gestational Malpresentation abortion rate rate rate delivery rate age rate rate Pregnancy 22% (11/49) 13% (4/31) 28% (9/23) 58% (18/31) 7% (2/29) 17% (5/29) after UAE Pregnancy 32% (11/34) 9% (2/23) 22% (5/23) 65% (15/23) 9% (2/22) 22% (5/23) after UAE for leiomyomata Pregnancy in 10–15% 4–6% 5–10% 22% 10% 5% the general population UAE ϭ uterine artery embolization.

Later that same year she underwent a myomectomy Our case 2 is the second reported twin gestation after secondary to persistent symptomatic leiomyomata. uterine artery embolization. Although she experienced The patient then underwent in vitro fertilization, preterm labor, the patient did not ultimately deliver until which resulted in the dichorionic twin gestation. She was 36 weeks’ gestation. admitted to the hospital for magnesium sulfate tocolysis Table 1 summarizes all published cases of pregnancies and a course of betamethasone. After successful tocoly- after uterine artery embolization.3–16 We used the MeSH sis, she was placed on prolonged bedrest. At 36 weeks terms “uterine artery embolization” and “embolization.” labor began and an uncomplicated cesarean delivery was All articles were checked also for related references. A performed for breech/vertex presentation. Her twins compilation and analysis of the 48 previously published were appropriately grown at 2359 g and 2469 g. The cases, plus our two cases, shows a 22% (11 of 49) rate of patient had an uncomplicated recovery, and she and the spontaneous abortion, a 17% (five of 29) rate of malpre- twins were discharged from the hospital on postopera- sentation, a 7% (two of 29) rate of small for gestational tive day 4. age infants, a 28% (nine of 32) rate of premature deliv- ery, a 58% (18 of 31) cesarean delivery rate, and a 13% (four of 31) rate of postpartum hemorrhage. If the anal- COMMENT ysis is limited to only women whose indication for Uterine artery embolization has been shown to be an embolization was symptomatic leiomyomata (eliminat- effective treatment for symptomatic uterine leiomyo- ing those with procedures performed for uterine arterio- mata, although no long-term studies have been pub- 2 venous malformation, gestational trophoblastic disease, lished. Spies reported improvement in heavy bleeding cervical pregnancy, placenta previa, placenta accreta, or in 90% (95% confidence interval [CI] 86%, 95%) and abruptio placentae), there is a 32% (11 of 34) rate of bulk symptoms in 91% (95% CI 86%, 95%) at 1 year. spontaneous abortion, a 22% (five of 23) rate of malpre- Outcomes data regarding women who desire future sentation, a 9% (two of 22) rate of small for gestational fertility are less clear and very limited. age infants, a 22% (five of 23) rate of premature delivery, In our case 1, because of contributing factors, such as a 65% (15 of 23) cesarean delivery rate, and a 9% (two of chorioamnionitis, prior myomectomy, and nonvisual- ized residual leiomyomata, neither the premature rup- 23) rate of postpartum hemorrhage. Reported rates in ture of membranes nor the uterine atony requiring hys- the general population for these events are 10–15% for terectomy can be definitively attributed to the prior spontaneous abortion, 5% for malpresentation, 10% for uterine artery embolization. Nonetheless, it is important smallness for gestational age, 5–10% for premature de- to be aware of the possible relationship between these livery, 22% for cesarean delivery, and 4–6% for postpar- 17,18 complications and prior uterine artery embolization be- tum hemorrhage. Table 2 compares these three cause of the increasing number of women desiring future groups. In interpreting these rates, it should be taken into fertility who are electing to undergo this therapy. Theo- consideration that the cesarean delivery rate was affected retically, devascularization of the myometrium resulting by elective cases as well as two patients whose prior from the embolization procedure could affect its ability myomectomies necessitated operative delivery. The in- to successfully contract following delivery. creased rate for malpresentations was possibly influ-

VOL. 100, NO. 5, PART 1, NOVEMBER 2002 Goldberg et al Pregnancy After UAE 871 enced by the presence of residual leiomyomata. Addi- subsequent successful intrauterine pregnancy. Aust N Z J tionally, information was not complete for each pub- Obstet Gynaecol 1994;34:492–3. lished pregnancy. The limited number of pregnancies 8. Chow TWP, Nwosu EC, Gould DA, Richmond DH. after uterine artery embolization reported in the litera- Pregnancy following successful embolisation of a uterine ture may reflect a reporting bias. Because many women vascular malformation. Br J Obstet Gynaecol 1995;102: have already undergone this procedure, it would seem 166–8. logical that many other unreported conceptions have 9. Gaens J, Desnyder L, Raat H, Stockx L, Wilms G, Baert occurred. AL. Selective transcatheter embolization of a uterine arte- Before uterine artery embolization can be regarded as riovenous malformation with preservation of the repro- ductive capacity. J Belge Radiol 1996;79:210–1. a safe procedure for women desiring future fertility, additional studies must be performed. Based on the few 10. McIvor J, Cameron EW. Pregnancy after uterine artery embolization to control haemorrhage from gestational tro- available data, women becoming pregnant after uterine phoblastic tumour. Br J Radiol 1996;69:624–9. artery embolization may be at significantly increased risk for postpartum hemorrhage, preterm delivery, cesarean 11. Stancato-Pasik A, Mitty HA, Richard HM, Eshkar N. Obstetric embolotherapy: Effect on menses and preg- delivery, and malpresentation. nancy. Radiology 1997;204:791–3. 12. Bradley EA. Transcatheter uterine artery embolisation to REFERENCES treat large uterine fibroids. Br J Obstet Gynaecol 1998;105: 1. Ravina JH, Herbreteau D, Ciraru-Vigneron N, Bouret JM, 235–40. Houdart E, Aymard A, et al. Arterial embolisation to treat 13. Ravina JH, Ciraru-Vigneron N, Aymard A, Le Dref O, uterine myomata. Lancet 1995;346:671–2. Merland JJ. Pregnancy after embolization of uterine myo- 2. Spies JB, Ascher SA, Roth AR, Kim J, Levy EB, Gomez- ma: Report of 12 cases. Fertil Steril 2000;73:1241–3. Jorge J. Uterine artery embolization for leiyomyomata. 14. Vashisht A, Smith JR, Thorpe-Beeston G, McCall J. Preg- Obstet Gynecol 2001;98:29–34. nancy subsequent to uterine artery embolization. Fertil 3. Forssman L, Lundberg J, Schersten T. Conservative treat- Steril 2001;75:1246–8. ment of uterine arteriovenous fistula. Acta Obstet Gynecol 15. Ciraru-Vigneron N, Ravina JH. Reply to letter to the Scand 1982;61:85–7. editor. Fertil Steril 2001;75:1247–8. 4. Chapman DR, Lutz MH. Report of a successful delivery 16. McLucas B. Pregnancy following uterine fibroid emboliza- after nonsurgical management of a choriocarcinoma-re- tion. Int J Gynaecol Obstet 2001;74:1–7. lated pelvic arteriovenous fistula. Am J Obstet Gynecol 17. Gabbe SG, Niebyl JR, Simpson JL, eds. Obstetrics—normal 1985;153:155–7. and problem pregnancies. 4th ed. New York: Churchill 5. Poppe W, VanAssche FA, Wilms G, Favril A, Baert A. Livingstone Inc., 2002. Pregnancy after transcatheter embolization of a uterine 18. American College of Obstetricians and Gynecologists. arteriovenous malformation. Am J Obstet Gynecol 1987; Postpartum hemorrhage. ACOG educational bulletin no. 156:1179–80. 243. Washington: American College of Obstetricians and 6. Tacchi D, Loose HW. Successful pregnancy after selective Gynecologists, 1998. embolization of a post-molar vascular malformation. Br J Obstet Gynaecol 1988;95;814–7. 7. Pattinson A. Cervical pregnancy following in vitro fertili- Received May 8, 2002. Received in revised form June 26, 2002. zation: Evacuation after uterine artery embolization with Accepted July 18, 2002.

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